Healthcare Provider Details

I. General information

NPI: 1205015179
Provider Name (Legal Business Name): SAMEKA DENTAL MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E BROADWAY
SOUTH BOSTON MA
02127-4406
US

IV. Provider business mailing address

500 E BROADWAY
SOUTH BOSTON MA
02127-4406
US

V. Phone/Fax

Practice location:
  • Phone: 617-268-2333
  • Fax: 617-268-8894
Mailing address:
  • Phone: 617-268-2333
  • Fax: 617-268-8894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number21211
License Number StateMA

VIII. Authorized Official

Name: DR. EKATERINA MAMULASHVILI
Title or Position: DENTIST
Credential: DMD
Phone: 617-268-2333